Treatment of perioral dermatitis: medications, topical treatments, creams, gels and more

Successful treatment relies primarily on initial patient education. Patient education includes, in particular, the removal of the triggering cause. If the triggering factor is the topical application of corticosteroids, their abrupt withdrawal may lead to a "rebound effect". The patient must be educated about this phenomenon.

Some experts recommend a strategy of gradually reducing the frequency of topical corticosteroid application. Another option is to switch to 1% hydrocortisone.

Another recommendation is to discontinue the use of any cosmetic products. At the very least, their use should be reduced to the minimum necessary (zero therapy). These are mainly moisturizers, make-up, night-time oily creams, etc.

It is recommended to wash the face only with clean water. Patients should avoid the use of fluoridated pastes or mouthwashes. Drying compresses such as black tea or pine water are suitable in the beginning.

For successful treatment, not only regular check-ups but also therapeutic and preventive measures should be followed.

Topical treatment

In mild cases, so-called individual topical treatment is generally recommended. Ivermectin, metronidazole and erythromycin appear to be the most suitable drugs. They should be used in the form of a gel, lotion or cream.

Table: Effects of different topically applied medicines

1. Ivermectin

Ivermectin belongs to the group of macrocyclic lactones, a subgroup of the avermectins. It is currently one of the most widely used antiparasitic drugs.

It is characterized by antiparasitic and anti-inflammatory effects. Its anti-inflammatory effects are the result of inhibition of the production of inflammatory cytokines. It increases the activation of anti-inflammatory cytokines.

The mechanism of the antiparasitic action of ivermectin lies in blocking neuromotor transmission of excitations in parasites.

In the parasite oesophagus, glutamate receptors associated with the chloride channel are affected. The binding sites for the neurotransmitter γ-aminobutyric acid (GABA) across the nerve synapse are blocked. This leads to an increase in the permeability of the cell membrane to chloride ions with hyperpolarization of the cell.

The result is paralysis of the oesophagus, starvation to death of the parasite.

Dosage and use

The preparation is applied once a day (preferably in the evening). The patient must be patient during treatment. The treatment may last up to 12-16 weeks. If there is no reduction in inflammatory symptoms within three months, the treatment should be discontinued.

The cream is applied to the skin in pea-sized amounts on the forehead, chin and nose. It is spread in a thin layer.

Side effects of topically applied ivermectin include:

• burning
• irritation
• itching
• dryness of the skin

2. Metronidazole

Metronidazole is a derivative of nitroimidazole. It has antimicrobial and antiprotozoal effects. It readily penetrates the cell membrane of unicellular organisms.

It does not penetrate human cells.

Metronidazole is effective in some highly inflammatory forms of perioral dermatitis. Its antibacterial and anti-inflammatory effect is thought to be exerted in treatment. In some cases, a combination of metronidazole with systemic antibiotics is necessary.

In dermatology, it is used in the form of a solution, gel, suspension or cream.

The mechanism of action is based on:

• suppression of bacterial flora
• reducing the number and activity of Demodex mites
• suppression of the inflammatory reaction
• inhibition of free radicals

Usage

Apply to affected areas twice daily in a thin layer. The skin must be washed and dried before application.

Common side effects include:

• Dry skin
• redness
• itching
• unpleasant sensations on the skin (burning, pain, stinging)
• skin irritation
• worsening of the symptoms of the disease

3. Topically applied antibiotics

Topically applied antibiotics are mainly characterised by their antimicrobial effect. Their therapeutic importance lies primarily in their ability to suppress microbial flora.

However, this base (vehicle) can cause unwanted redness, peeling and burning. Topical antibiotics are not suitable for long-term application due to the risk of resistance.

They have the advantage of being able to be combined with other topical and general medicines. Combination with general antibiotics is not recommended, as such a combination may increase the risk of bacterial resistance. Currently, the most commonly used preparations are those containing erythromycin and clindamycin.

4. Azelaic acid

Azelaic acid is a saturated dicarboxylic acid. It is found in wheat, barley and rye and is also produced by the yeast Malassezia furfur.

In practice, it is mainly used in the treatment of acne. Azelaic acid is characterised by the following effects:

• comedolytic
• antibacterial
• anti-inflammatory

The exact mechanism of action of azelaic acid is not elucidated. It is believed that the mechanism of action lies in its ability to normalise disturbed skin cornification, inhibit bacterial growth and reduce inflammation.

The most common side effects of azelaic acid include:

• Itching
• burning
• redness

Azelaic acid has no teratogenic or mutagenic effects and does not exhibit photosensitizing activity.

5. Adapalene

Adapalene belongs to the third generation of retinoids. Retinoids are derivatives of retinol (vitamin A). The different generations of retinoids differ in their action, stability and irritant potential. Adapalene (a derivative of naphthoic acid) was introduced in 1996.

It is mainly used for the treatment of acne. It differs from other retinoids in the following properties:

• greater stability
• lower irritability
• more stable to sunlight
• its lipophilic structure allows greater penetration of sebaceous follicles

It is used in the treatment of perioral dermatitis mainly for its ability to reduce inflammatory skin manifestations (papules, pustules). It has comedolytic, keratolytic, anti-inflammatory and self-static effects.

In the human body, it acts by the following mechanisms:

• it affects cell division (inhibits)
• affects the keratinization process and inflammatory reactions
• inhibits the chemotactic and chemokinetic reaction of leukocytes
• inhibits lipooxidation of arachidonic acid

Side effects:

• redness
• dryness
• itching
• burning

Side effects of topical retinoids occur mainly at the beginning of treatment. Their frequency of occurrence and degree of severity depend on the following factors:

• the type and concentration of the topical retinoid
• the method of application
• skin type
• the use of moisturizers
• exposure to external environmental factors (sunlight, cold wind, warm humid environment)

Topical retinoids should not be used in pregnancy, while breastfeeding and in children under 12 years of age.

6. Topical antifungals

This group includes: natamycin, nystatin, clotrimazole, ketoconazole, terbinafine and ciclopiroxolamine. Topical antifungals are usually combined with other treatments. Ketoconazole is suitable for the concomitant treatment of perioral and seborrhoeic dermatitis.

Jarisch's solution and perioral dermatitis

For the topical treatment of perioral dermatitis, Jarisch's solution (solutio Jarisch) is often required by patients. The active substance of the solution is boric acid. It has antipruriginative, mild disinfectant, anti-inflammatory and keratoplastic effects. It is used to superficially soothe irritated skin.

Side effects of boric acid occur mainly with inappropriate and prolonged application. There is a risk of accumulation of boric acid in the human body.

Boron is also ingested from foods such as vegetables, oranges, grapes and cereals. Approximately 100 milligrams of boron per day is ingested in this way. Boron compounds and boric acid should not be used in children under 10 years of age due to their cumulative toxicity and increased toxicity.

The exception is very short-term administration to small areas at low concentrations up to 3%.

What are the symptoms of poisoning?

The following table gives examples of acute and chronic poisoning:

Systemic treatment

For severe forms of oral dermatitis, systemic treatment is recommended.

The following preparations are used in systemic treatment:

1. antibiotics: tetracyclines (doxycycline, minocycline), macrolides (erythromycin, azithromycin)
2. nitroimidazoles - metronidazole
3. corticosteroids
4. retinoids (isotretinoin)

1. Antibiotics

Tetracyclines

Tetracyclines are the first line of systemic treatment for perioral dermatitis. Doxycycline is often used.

The pathophysiology of the inflammatory lesions of perioral dermatitis is partly a manifestation of a neutrophil-mediated process. Doxycycline has been shown to inhibit neutrophil activity and some pro-inflammatory responses.

Dosage

In the treatment of perioral dermatitis, their low dose is used in a long-term regimen. A dose of 100 mg once daily extended over a period of 3 to 4 months is recommended.

Side effects

Tetracycline antibiotics have several side effects. For this reason, patient education is important. Side effects include:

• teratogenicity
• may cause discoloration of the teeth
• photosensitivity
• vaginal candidiasis
• poorer gastrointestinal tolerance (nausea, epigastric pain, diarrhoea)

Method of use:

Doxycycline-containing product should be taken after or during meals. It should be taken at regular intervals with sufficient fluid. It should not be taken with milk. Co-administration of milk, dairy products and substances containing divalent and trivalent metals may reduce the effectiveness of doxycycline by up to 10-30 %.

2. Nitroimidazoles - metronidazole

Metronidazole is a 5-nitroimidazole derivative with antiprotozoal and antimicrobial activity. It is applied for a maximum of 5-10 days. Longer periods of treatment with metronidazole are not recommended due to adverse effects.

3. Corticosteroids

Short-term oral administration of corticosteroids in the pulse system is recommended for markedly inflammatory manifestations of the disease. Combination with antibiotics is appropriate.

4. Isotretinoin

Isotretinoin is recommended for the treatment of severe forms of perioral dermatitis. It was originally used to treat severe and resistant forms of acne.

Isotretinoin belongs to the group of first-generation synthetic retinoids. Its effects include:

• reduction of sebum secretion
• affecting the proliferation of hair follicles
• reducing colonisation by Propionibacterium acnes bacteria
• suppression of inflammatory manifestations

Isotretinoin treatment is very well tolerated. However, we must also be aware of the possible side effects:

• teratogenicity and embryotoxicity
• psychiatric side effects - depression
• mucosal and skin complications - dry lips, dry nasal mucosa, thinning hair
• slow wound healing
• ocular complications - dry eye syndrome, visual impairment
• nervous and musculoskeletal side effects - headache, fatigue, lethargy, muscle and joint pain
• digestive disorders - nausea, lack of appetite, vomiting, abdominal pain
• pulmonary side effects - bronchospasm, respiratory infections, voice disorders
• laboratory abnormalities - changes in lipid metabolism, increased red blood cell sedimentation, changes in sugar levels
• other side effects (menstrual cycle disorders)